\TOI-]ND CLOSI-]RE

M. Eileem Basbara, DPM

Successful wouncl closure depends on many fac- cotton may fragment or break down in the bocly
tors that must be understoocl and evaluated when after a long period of time. Polyester, polypropy-
accessing the patient's ability to heal uneventful- lene and stainless steel are far less likely to break
ly. These factors include an assessment of the down in the body. Nonabsorbable sutures in the
health and nourishment of the patient, along with skin are normally removed while those within the
a thorough medical history to pinpoint any previ- body in deeper tissues become encapsulated.
ous problems with healing. This will a1low the The absorption process of absorbable
surgeon to be prepared for alternative material sutures is manifested by a gradual, almost linear
and techniques in the presence of factors that will loss of tensile strength over the first few weeks
delay healing. The presence of infection is one of following implantation within the body. This
the main reasons for delayed wound healing. In gradual decline is followed by the second stage
addition to poor physical condition, diabetes mel- of absorption with loss of suture mass. During
litus, cefiain meclications such as steroid therapy. the breakclown process, leucocytic cellular
older age, and capillary oozing all contribute to a responses occllr that serve to remove cellular
delayed host response to healing. Sutures and the debris as well as sutllre material from the line of
newest techniques cannot compensate for these suture tissue approximation. (See table 1 for
abnormalities at the patient's cellular level, btit by types of suture materials ancl construction.)
understanding each patient individually, the sur-
geon will be able to make the proper selection of SUTI]RE SIZE
material and technique for the least complicated
wound closure. Sutures range in sizes from7, the largest, to 11-0,
the smallest. Sutures in the larger diameters from
SUTURE CHARACTERISTICS 7 to 2 are usually used as retention sutures.
Those in the 7, 0, 2-0 - 4-0 diameter are usually
There are two basic types of suture materials, used in general sur5aery closure. Most frequently,
absorbable and nonabsorbable. Absorbable the 2-0, 3-0, 4-0, 5-0, 6-0, and 7-0 diameter
sutures can be further divided into surgicai gut sutures are used in plastic/cuticular and fascial
(natural) sutures and synthetic absorbable layer/tendon sllrgery. Diameters of 6-0, 7-0, B-0
sutures. Surgical gut sutures are made from ani- r1p to a 77-0 diameter are used frequently in
mal tissues and are digested and absorbed by tis- microsurgical/opthalmic surgery. The diameter of
sue enzymes and phagocytes. Synthetic sutures is standardizecl by the United States
absorbable sutures are made from materials, such Pharmacopeia.
as polyglycolic acid (PGA). PGA and lactic acid, Sutures are made either as monofilament or
glycolic acid and trimethylene, or polydixoa- multifilament. Monofilament consists of a single
mone. These sutures are absorbed by the process suture filament and is known for its smoothness
of hydrolysis, which means that the material is through tissue. Multifilament consists of a number
broken down by contact with body fluids. There of strands braided or twisted together. Muitifila-
are a variety of different types of nonabsorbable ment sutures are known for their handling
sutures avaiiable, including silk, cotton, synthetic properties.
nylon, polyester, polypropylene and stainless Polyglycolic acid sutures are treated with
steel. Synthetic materials such as silk, nylon, or poloxamer 1BB, which acts to reduce friction,

441
 IABLE 1.

NONABSORBABLE SUTURES
Generic Name Trade Name Construction
Nylon Dermaion (monofilament) Uncoated monofilament nylon
Surgilon (multifilament) Braided nylon fibers with silicone coating
Ethilon Polyamide polymer
Nurolon Polyamide polymer
Polypropylene Surgilene (monofilament) Monofilament of linear hydrocarbon polymer
Prolene, Supramid, Deklene Polymer of Propylene
Polybutester Novafil (monofilament) A copolymer (B4o/o polymer) Poly (butylene)
terephthalate (760/o polymer) tetramethylene
ether gycolterephthalate
Prolene
Polyester (coated) TICRON silicone-treated fiber, Braided polyester fibers
braided, Polydek
Ethibond, Tevdek Polyester polyethylene terephthalate coated
with polybutilate
Polyester (uncoated) Braided mulitfilament
Dacron Uncoated polyester fiber
Mersilene Polyester polyethyiene terephthalate
Stainless Steel Monofilament, Ethicon mono-
filament and multifilament
stainless steel Ferrous Alloy
Flexon (multistrand) Twisted multistrand of Ferrous Alloy

ABSORBABLES
Surgical Gut D&G surgical gut Protein acesous sheep or beef intestine lining
plain, mild chromic, Ethicon surgical gut, Collagen derived from healthy animals
chromic gut Deknatel surgical gut
Synthetic absorbables Coated Dexon Plus Same as Dexon S with a Polaxamer 1BB coating
(multifilament)
Coated Vicryl Copolymer of lactide & glycolide coated with
polygalactin 370 & calcium sterate
PDS Polyester polymer
Dexon S (monofilament) Glycolic Acid homopolymer
Uncoated Vicryl
Vicryl (monofilament)
Dexon S (multifilament)
Maxon (monofilament) Monofilament strand of 67% PGA & 33o/o
trimethalene carbonate
silk D&G silicone treated
Ethicon silk Raw siik
Deknatel silk

448
allowing the sutures to be pulled through tissue MONOFIIAMENT N]-YLON (DERMALON,
more easily. Treated or chromic gut undergoes ETHILON)
treatment in a chromium salt solution which
allows the suture to resist body enzymes, pro- Monofilament nylon is a nonabsorbable synthetic
longing absorption time over 90 days. Plain gut is suture material. It is popular because of its mini-
digested within 7 to 10 days. Plain gut may be ma1 tissue reactivity. It has a very 1ow tissue drag
utilized in tissues which heal rapidly, such as and high tensile strength due to its monofilament
superficial blood vessels. Most suture materials construction. This smoothness also allows for
do not improve the rate of normal wound healing ease of removal from tissues. However extra ties
and in fact they may calrse tissue reaction. A for- are necessary to prevent slippage. Nurolon and
eign body response to the sllture material may Surgilon, synthetic braided nylon fibers allow
occur and consideration must be given to the excellent knot securiry but offer no great advan-
type of material and site of implantation to mini- tage over monofilament nylon.
mize the likelihood of this response.
POLYPROPYI,ENE
FREQUENTLY USED SUTURES
Monofilament polypropylene (Surgilene, Prolene)
POLYGLYCOLIC ACID SUTURES A]\D is a linear hydrocarbon fiber processed as a
POLYGIA.CTIN 91.O. monofilament suture. As a synthetic nonab-
sorbable suture, it is extremely smooth, totally
Polyglycolic acid (Dexon) is a synthetic unaffected by tissue fluids and retains its tensile
homopolymer of glycolic acid. Because it is .l strength indefinitely. Due to these properties,
man made material, the suture strands contain no polypropylene is indicated in the closing of con-
collagenous protein, antigens or pyrogens. Less taminated wounds. However, due to the materi-
tissue reaction and inflammation lead to less al's memory and smooth surface, it too has a
patient discomfofi during healing. This is in con- propensiry to allow slippage of the knot.
trast to surgical gut which is likely to cause
greater tissue reaction. The diameter and tensile POLYESTER
strength of polyglycolic acid sutllres can be con-
trolled during manufacturing. This makes it easier Polyester sutures are made from a nonabsorbable
to produce uniform strands of greater tensile synthetic material which is retained for an indefi-
strength than with the production of surgical gut. nite period of time. Having the greatest tensile
Polyglactin 910 (Vicryl) is a copolymer of strength of any suture allows for its use in liga-
lactide and glycolide coated with polyglactrn 370 ment and capsule repair, and in peripheral vascu-
and calcium stearates. It is similar biologically 1ar procedures requiring tissue to graft suturing.

and physically to polyglycolic acid sutures. Maxi- Untreated polyester fibers (polyethylene
mum reabsorption is reached within 90 days but terephthalate- Mersilene, Dacron) can be closely
adequate strength is maintained for up to 21 braided into multifilament strands to yield sutures
days. Its major uses are in tissue layer closure which are stronger than natural fibers. This com-
(fascia, muscle, tendon, subcutaneous fat and bination affords minimal tissue reaction while
subcuticular skin). Polyglactin 910 coated is avail- providing excellent knot security. Ticron is a
able either dyed violet or undyed (natural). The silicone-treated braided polyester sutllre which
dye is used to enhance visibility in tissues. Dexon has high tensile strength and smooth, supple han-
S, an uncoated second generation suture has finer dling. Ethibond is braided polyester coated with
filaments which provide a tighter, smoother braid polybutilate w-hich acts as a suture lubricant to
for optimum handling as compared to the origi- allow for the smooth passage of suture through
nal Dexon. Dexon Plus was also introduced and tissues. Polydek and Ethiflex are polyester sutures
has a smooth coating of poloxamer 1BB providing treated with varying degrees of Teflon coating to
easier handling and less tissue drag. In addition, ease the suture through tissues without causing
they aliow repositioning of a square knot. insult. Ethibond has been used successfully in

449
podiatric surgery due to its inert properties and continuous stitches can be sewn as mattress
ability to minimize tissue reaction. stitches. In a mattress stitch the needle and suture
is passed through the tissue twice before tying
POLYDIOXANONE the stitch. These stitches are used to alter the
angle at which the suture puils on the wound
PDS (polydioxanone) is a monifilament synthetic edges. (Fig. 2)
absorbable suture preparecl from polyester poly Interrupted mattress stitches include the ver-
(p-dioxanone). It was the first absorbable suture
tical mattress which inverts the wound edges, the
to provide a great degree of flexibility while horizontal mattress. which everts the wound
offering at least 6 weeks of wound support. After edges, and the figure-of-eight (Fig. 3). Finally,
implantation for approximately 2 weeks, 70o/ct of continuous mattress stitches inch-rde continuous
its original strength remains. At four weeks, inverting, continr:ous everting and the purse
approximately 50% of its original strength string continuous stitch (Fig. ,1).
remains. PDS has been used successfully in all Retention stitches are used to reinforce the
types of forefoot surgery most notably Austin primary suture line, thus a heavy strong suture
bunion correction and digital surgery. material is used. (Fig. 5) Retention suture bolsters
or bumpers can be r-rsed to prevent the hear,y
STAINLESS STEEL suture materials from cutting into the skin.
Stainless steel has the highest tensile strength of
any nonabsorbable suture material. The knot Surgical Knots
security with monofilament stainless steel is fair, Surgical knots are essential for the success of a
requiring special tying techniques to prevent slip- surgical procedure. Certain principles are general-
page. Usually the ends are twisted together rather ly foliowed including the use of small knots to
than tied to secure tissue approximation. Knot minimize foreign body reactions arrd the avoid-
security is better with multifilament stainless steel, ance of tying sutures too tightly which can lead
which can be tied with the same techniques as to tissue strangulation and necrosis. In tightening
braided nonabsorbable sutures. Flexon is a twist- the sutures, one must also make an allowance for
ed multi-strand of a ferrous alloy. It is used for postoperative sweiling and edema.
tendon and ligament and bone repair, and in The most frequently used surgical knot is
cases of contaminated wounds. The ROTO-Grip the square knot (Fig. 6). A variation of the square
needle which can be attached to certain monofil- knot is the Surgeon's knot, where an extra throw
ament sutures, is swaged to the suture so as to is made to prevent slippage (Fig. 7). The combi-
allow the needle to turn 360 degrees on the nation knot is useful when the knot must be
suture. adjusted or when access is limited or difficult
(Fio .R r

STITCH TECHMQUES
The two major types of surgical stitches used by Ligatures
surgeons to close wounds are interrupted stitches A ligature is a strand of suture material used to tie
and continuous stitches. Interrupted over-and- off incised or tortuous blood vessels, thereby
over, continuous (or running) over-and-over, and establishing hemostasis. Metal ligating clips are
subcuticular stitches are shown (Fig. 1A, B, C) sometimes used instead of sutures to ligate blood
In the interrupted stitch, each stitch is sepa- vessels. Ligatures are selected for use according
rate and tied independently of the other stitches. to the location and size of the blood vessels
These stitches continue to offer support even if involved. The obiective is to select the finest size
one breaks. Continuous stitching involves making of material which will effectively prevent blood
more than one stitch with a single suture strand flow. In general, this means that the deeper the
before the knot is tied. This stitch may be done blood vessel within the body, the larger the
more rapidly than interrupted stitching since blood vessel within the body, and the larger the
there are fewer knots to tie. Both interrupted and diameter of the ligature necessary to gain

450
Ftg. 1A. Running Stitch Fig. 18. Interrupted Stitch (simple)

Fig. lC. Suhcuticular Stitch Flg. 2. Interrupted Vertical Mattress Stitch

457
Fig. 3. Figure-of-Eight Fig. 4. Purse String

Fig. 6. Square Knot

Fig. 5. Retention Stitches

452
 Eyed needles are available in three types;
round, square and split-eye (or French eye). Sur-
gical needles have distinguishing characteristics
which include the curvature (straight or curve
shaft), needle length, wire diameter, and the type
of point. The common needle shapes include;
straight, 3/8 circle, 7/2 circle, and 5/B circle.
Straight needles are primarily used for skin clo-
sure or tendon repair.
Curwed needles are described based on arc
length, chord length, and including angle. The
arc length is the length of the needle as measured
along its arc, or curve. The chord length refers to
Fig. 7. Surgeons Knot
the straight line distance measured berween the
point and the end of a curved needle. Included
angle is the number of degrees included in the
ang1e.
Needle points may be either tapered, cut-
ting, or blunt. Tapered needle points have a
round shaft with a flattened portion to hold the
needle in the needle holder. Taper point needles
are used in tissue that offers little resistance to
the needle, such as fascia, subcutaneous tissue,
or vascular tissue. As a general rule, this type of
needle is used for softer red tissue with ample
blood supply, whereas cutting edge needles are
used for tougher white tissue, such as tendon and
ligaments.
Cutting edge needles are used in tissues
Fig. 8. Combination Knot such as skin, periosteum and bone. This type of
needle is available in many different configura-
hemostasis. Ligatures are available in one of two tions. The most commonly used cutting edge
ways; in pre-cut lengths of 18", 24u,30u ald 54", needle is the reverse cutting. The reverse cutting
or as a ligature reel. In general, the larger the appears in a cross section as an upended triangle.
diameter, the longer the pre-cut length. This needle will not tend to cut up through the
tissue because the sharp edge is on the outer cur-
IIEEDLES vature. This makes it less likely for the suture to
tear through the tissue.
Sutures are attachedto needles in two basic ways. Conventional or regular cutting needles are
One way is for the suture to be attached to an eye- used in tough tissues, such as tendon and skin,
less needle by the drilled-end or flange method. where a laper point needle cannot easily pene-
The second way is to thread a suture through a trate. Other variations of cutting edge needles
hole or eye located in the shaft of the needle. include the spatula, penetrating point, diamond
Eyeless needles or swaged needles have the point, and lancet needles. The spatula point is
suture attached within the metal of the needle so diamond shaped with the cutting edges in the lat-
the diameter of the needle is not significantly eral plane only and widens out to allow easy pas-
greater than the diameter of the suture. This mini- sage of the shaft through the tissue. The spatula
mizes trauma to the tissue and leakage at anasto- is generally used in eye surgery for repair of mus-
motic sites. The term swaging refers to the pro- cle and detached retina, and may be used for
cess of attaching suture strands to eyeless eyelid plastic surgery.
needles.

453
 A diamond taper (diamond point or dia-
mond tip) has a side cutting point on a tapered TABLE 2
shaft. The tip is smaller than the shaft to prevent ABBREVIATIONS FOR COMMONLY
excessive cutting. This type of needle point is USED ASTRAIA.C NEEDLES
used for extra penetration. For example, the dia-
mond taper is generally used on ligamentous, CP Cutting point
tendinous, or fibrous tissue. Its greatest use is in CPS Conventional plastic surgery
thoracic, orthopedic, and revisional surgery. FS For skin
The penetrating point is similar to the dia- FSL For skin J.arger
mond point, however the cutting edge is on the FSLX For skin large extra
tip only, as compared to the diamond point P Plastic sllrgery
whose cutting edge extends further back on the PC Precision cosmetic
needle. The greatest demand for the penetrating PS Plastic surgery
point is in vascular surgery proceclures. SH Small half
The lancet needle primarily employed in V Taper cut needle
opthalmic surgery is a spatula with a cutting
lancet point. It is a rer.erse cutting needle with ABBREVIATIONS OF SWAGED
the bottom cut off, and an inverted lancet is a ATRAUMATIC NEEDLES
lancet turned over.
A blr-rnt point needle has a tapered body with NEEDLE CODE:
a rounded point and no cutting edge. It is usecl S Straight needle
primarily for orp;an repair where the blunt tip will 1./2circle No additional letter
help prevent the needle from piercing blood ves- 3/B circle E
se1s. It is also used in parasternal closure. 7/1 circle O
Precision point cutting or hand honecl 5/8 circle Repeated letter (TT)
reverse cutting needles are used typically for C Reverse cutting
plastic or cuticular procedures. The SBE (s1im DT or DG l)iamond point
blade edge) needle is recommended for skin clo- PR Hand honed reverse cutting
sure because it is atraumatic, and a hole can not SC or MC Conventional cutting
be visualized. T Taper point
Current research and development in the
needle market is refining a needle made of a
more durable alloy to prevent breakage while BIBLIOGRAPTIY
maintaining a precision micro point and body for Beskin JL, Sanders RA, Hunger SC: Surgical repair of Achilles tenclon
skin closure. See Table 2 for needle abbreviations rupture. Am J Spotts Mecl 75:1-8, 7L)Bf .

Calhoun TR, Krtten CM: Polypropylene suture - is it safe?. / [a.sc

and descriptions. 5r;rg 4(1):98-100, 1986,
Colclinon BN{: Closure of wounds uncler tension. The horizontal
mattress snlrtre . Arch Dermatol.125:7789 1190, 1989.
SUMMARY Peaccrck EE Jr, Van $flinkle W.lr: Wound Rep.4ir 2nd Ed. W.B. Sar.in-
ders, Philadelphi:t, 7976.
Suture manufacturers are currently developing Reecl D, \Yatanbae NI, Izenberg 1': Gener:rl Principles of Skin
Surgery. In Epstein Fl, Epstein E .lr (eds) Skin Sur1qery Springficlcl
new materials or rnodifying current ones, so as to I11, Charles C. Thomas p. 80, 1982.
enhance strength while maintaining tissue reac- Shcm,in NIA, Gastvi.r'ith CNI: Detrimental ef1ccts of cigerette smoking
tion. Future needles will need to be more durable on lower extremity wouncl hcaling. .J I'-oot Surg, 2L):81 8f ,1,990.
Simmoncls -Wl: Use of bolsters in dermatologic sl1rge1y. J Dermatol
and less traumatic to tissues as specific needs Surg Oncol 3:281-281,. 7977 .

arise. Suture Atlas otnd Sutut"es Selectiort. Davis and Geck, Pearl River, NY,
Americ:rn Cyanan-rid Company, 1988.
\rith the proper needle and suture selection Trimbos JB. Brohinr R. vanfulssel EJ: Factors reiadng to the volr"rme
wound healing can be enhanced resulting in min- of surgicai knots. IntJ Gyt'tcol Obstet30:355 359,7990.
Yu GV. Cavaliere R: Slrture material. .l Am Podidtr Assoc 73:61, 1983.
imal scarring and optimal strength.

454